Republic of the Philippines

Department of Education
Region III
SCHOOLS Division of Mabalacat City
Atlu-Bola High School

Atlu-Bola High School Limited F2F Classes

Student Permission Form, Release and Hold Harmless

In consideration of ________________________________________(NAME OF STUDENT)

being allowed to attend and participate in-person in Atlu-Bola High School Limited F2F Classes
to include but not limited to educational, co-curricular, and extracurricular programs, the
undersigned acknowledges and agrees that:
1. The risk to have contact with individuals, who have been exposed to and/or have been
diagnosed with one or more communicable diseases, including but not limited to
Corona Virus Disease 2019 (COVID19) or other medical conditions, diseases, or maladies
does exist, and, despite school’s good faith implementation of the Inter-Agency Task
Force guidelines, it is impossible to eliminate the risk that Student might be exposed to
and/or become infected through contact with or close proximity with an individual with
a communicable disease. Risk from contracting such communicable disease might
include illness, permanent disability, or death.
2. COVID-19 is a new disease and there is limited information regarding risk factors for
severe disease. Based on currently available information and clinical expertise, older
adults and people of any age who have serious underlying medical conditions might be
at higher risk for severe illness from COVID-19. Based on Department of Health
guidance, those at high-risk for severe illness from COVID-19 are: people 65 years and
older; people who live in a nursing home or long-term facility.
Those at severe risk also include people of all ages with underlying medical conditions,
particularly if not well controlled, including, but not limited to: chronic lung disease or
moderate to severe asthma; serious heart conditions; those who are
immunocompromised (many conditions can cause a person to be immunocompromised,
including cancer treatment, smoking, bone marrow or organ transplantation, immune
deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and
other immune weakening medications); severe obesity (body mass index [BMI] of 40 or
higher); diabetes; chronic kidney disease undergoing dialysis; and, liver disease.
3. By signing below the undersigned acknowledges that Student does not have an
underlying medical condition, as referenced herein, or that if Student has such
underlying medical condition that the undersigned will first obtain written permission
from a licensed healthcare professional prior to Student attending or participating in
School Activities, which written approval will be provided to school in advance of
attendance or participation.

4. People with COVID-19 have had a wide range of symptoms reported – ranging from mild
symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the
virus. People with these symptoms may have COVID-19: cough; shortness of breath or
difficulty breathing; fever of 100.4°F (38°C); chills; muscle pain; sore throat; new loss of
taste or smell. This list is not all possible symptoms. Other less common symptoms have
been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea.

Address: Northville 16, Atlu-Bola, Mabalacat City, Pampanga

Email Address: atlubola.hs@depedmabalacat.org
“LEADING PEOPLE TOWARDS PROGRESS”
 Republic of the Philippines
Department of Education
Region III
SCHOOLS Division of Mabalacat City
Atlu-Bola High School

5. Student will not attend limited F2F classes and Student or Student’s parent or
contact with anyone with a confirmed COVID-19 diagnosis in the last 14 days.

6. Student will not attend or participate in school limited F2F classes if they are subject to
state or federal government directed quarantine or isolation.
7. School retains the right to deny Student’s attendance or participation in school limited
F2FL classes, if School determines that such attendance or participation is an undue
health risk to Student or others. School similarly has the right to deny any other
individual from attending School Activities if said individual’s attendance poses an undue
health risk to that individual or others. School reserves the right to conduct screening
measures, including but not limited to, taking Student's temperature and inquiring
about current symptoms, before Student may attend a School practice or event.
8. THE UNDERSIGNED KNOWINGLY AND FREELY ASSUMES ALL SUCH RISKS for Student’s
attendance or participation in School Activities.
9. The undersigned agrees that the undersigned and Student will comply with any safety or
health related rules, terms, or conditions for participation in School Activities
10. If Student or Student’s parent or legal guardian observes any unusual, significant hazard
during their presence or participation in school limited F2F classes, Student or Student’s
parent or guardian will remove Student from participation and bring such observation to
the attention of the nearest School employee.
After fully and carefully considering all the potential risks involved, I hereby assume the same
and agree to release and hold-harmless to Atlu-Bola High School and its employees, officers,
agents, contractors and concessionaires from and against, all claims and liability resulting from
exposure to disease-causing organisms and objects, such as COVID-19, associated with Student
participating in school limited F2F classes, to include, but not limited to educational, co-
curricular, or extracurricular programs.

Date: _______________________

_____________________________________ __________________________
Printed Name of Student Signature of Student

_____________________________________ __________________________
Grade and Section Contact Number of Student

_____________________________________ _______________________________
Printed Name of Parent/Legal Guardian Signature of Parent/Legal Guardian

_____________________________________
Contact Number of Parent/Legal Guardian

Address: Northville 16, Atlu-Bola, Mabalacat City, Pampanga

Email Address: atlubola.hs@depedmabalacat.org
“LEADING PEOPLE TOWARDS PROGRESS”
 Republic of the Philippines
Department of Education
Region III
SCHOOLS Division of Mabalacat City
Atlu-Bola High School

Address: Northville 16, Atlu-Bola, Mabalacat City, Pampanga

Email Address: atlubola.hs@depedmabalacat.org
“LEADING PEOPLE TOWARDS PROGRESS”